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February 14, 2001

Access vs Quality Assurance: the e-Health Conundrum

Author Affiliations

Copyright 2001 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2001American Medical AssociationThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

JAMA. 2001;285(6):807. doi:10.1001/jama.285.6.807-JMS0214-4-1

The rise of e-health1 is inexorable, and its inherent e-commerce message is consistently upbeat. Microsoft tells consumers that with its new e-health systems "[t]he patient is definitely in charge"2 while Intel markets digital credentialing to physicians under the bullet "provide better patient care."3 However, there seems to be little reflection on the accuracy of such predictions or their deeper professional implications. Indeed, the American Medical Association (AMA) Web page devoted to e-health, entitled "Finding solutions to the e-health puzzle: AMA puts the pieces together for you and your patients,"4 is disturbingly silent as to the legal and ethical issues that must be navigated during this fundamental re-engineering of the delivery system.

At the core of the e-health debate is the tension between access and quality assurance. e-health destroys the single-point, gatekeeper model of access, promising multiple entry points and, thereafter access to health care that is nonlinear and less hierarchical.1 Established information brokers, including health care professionals, risk disintermediation, replaced by direct distribution of information to patients, while conventionally aggregated medical functions (such as health data collection and diagnosis) face disaggregation by home-based devices and automated teller machine–like models of medical practice. These technologies should decrease costs and improve access, yet pose serious issues for quality assurance systems. Systems based on licensure or malpractice law are premised on a single point of entry identifiably located in physical space and will be ineffective to police a delivery system that is no longer based on physicality or the preeminence of the traditional patient-physician relationship.5

Ethical structures may not fare any better. Transferring the core tenets of the patient-physician relationship to managed care has been difficult enough.6 But e-health poses even more difficult problems. Choice and communication (aided by the promise of extracting administrative costs from the healthcare delivery system) should dramatically improve access. Yet, e-health's lack of physicality, its depersonalization, anonymity, and even coldness challenge usual conceptions of competence and compassion. Further, multipoint entry into the delivery system makes continuity difficult to achieve, while health advice sites based on e-commerce paradigms involve considerable conflicts of interest.7 Finally, e-health marketing practices and privacy concerns frequently seem to involve the commodification of patients and patient data.

e-Health has great potential for good. Highly efficient national medical markets, around-the-clock service and the seamless integration of products and services no longer should be the stuff of dreams. The ability to heavily personalize computer-mediated relationships may rehabilitate patient-physician relationships eroded by years of managed care, while the Web's ability to deliver rich information directly to consumers could reverse centuries of damaging informational asymmetry between patient and physician.

To achieve the promise of e-health, ethical and legal structures must be refurbished to further demand the provision of quality medical information, untainted by patient sorting costs or provider self-interest. Regulatory systems must be changed so that they are no longer premised on ties with some physical place. Legal and ethical constructs must be informed by e-health codes of conduct and computer-mediated data quality solutions.8 Different groups of health care professionals may cling to narrow conceptions of the "practice of medicine" However, the future of meaningful quality assurance is dependent on accepting that, at least from the patient's perspective, medical advice sites, drug manufacturers, and health insurers all practice medicine and must be held to the highest standards.

In other areas of the economy where e-commerce came first and law struggled to keep up, legislatures have been convinced to pass arguably anticonsumer legislation in such areas of intellectual property and software licensing. With e-health the early signs are more positive, as the US Department of Health and Human Services has sought valiantly to reconcile cost extraction and patient rights in its privacy regulations.9 The serious challenges posed by e-health should not be underestimated as information, diagnosis, treatment, and care are delivered through unfamiliar channels. However, there is still time to reengineer legal and ethical codes to marry increased access to quality assurance and avoid the abyss of a computer-mediated sequel to the worst and most dehumanizing aspects of managed care.

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Not Available, Not Available http://www.ama-assn.org/ama/pub/category/2562.html. Accessed October 9, 2000
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